Examining Moral Injury Awareness in a Clinical Setting

In   Issue Volume 26 No.1 .

M Kopacz, G L Charpeid, L A Hollenbeck, J Lockman

Abstract

Moral injury is a relatively novel clinical construct recognized as a focus of concern in some military veteran populations. This short communication presents findings from a descriptive survey examining awareness of moral injury in a clinical setting specialized in veteran health services and treatment. An online survey was distributed to personnel (n=900) at a Department of Veterans Affairs Medical Center. This survey yielded n=106 (11.8%) responses. Self-perceived awareness was about evenly divided between developed and underdeveloped. Respondents saw moral injury as being chiefly the domain of mental hygiene service providers, followed by chaplains, medical, and nursing staff. Respondents overwhelmingly saw moral injury as relevant to the health of veterans, yet felt that not enough is being done to address this issue. The findings highlight a critical need for continued efforts at increasing awareness of moral injury in clinical settings as well as developing support options.

Keywords: moral injury; veterans; awareness

Introduction

An emerging literature has described moral injury (MI) as a focus of clinical concern in some veteran populations. MI represents a clinical state of psychological distress manifesting as “a syndrome of shame, self-handicapping, anger, and demoralization.”1(p. 408) It is thought to arise in military personnel following a morally injurious experience, defined as “an act of transgression that severely and abruptly contradicts an individual’s personal or shared expectation about the rules or the code of conduct, either during the event or at some point afterwards.”2(p. 700)

As a focus of clinical concern, one could reasonably argue that MI awareness among clinical service providers is critical, especially in settings responsible for veteran health services and treatment. In simple terms, awareness ensures that providers remain attentive to the needs of their patients/clients. One author went so far as to underscore “the need for clinical focus on the establishment and maintenance of postdeployment social support for military personnel” in moderating the negative effects of moral injury.3(p.198) Yet MI awareness in clinical settings has never previously been examined.

United States Department of Veterans Affairs (VA) Medical Centers (MCs) represent a unique clinical setting for examining MI awareness. The VA oversees the largest integrated healthcare system in the United States, with the stated mission of supporting the health of America’s veteran population. In this short communication, we present the findings of a descriptive survey examining MI awareness which was recently distributed to personnel at a VAMC in upstate New York. Such preliminary findings could serve to facilitate discussion and future research with regards to supporting veterans affected by MI.

Methods

A survey was organized in anticipation of an upcoming local MI education campaign and was intended to gauge baseline self-perceived awareness of MI among staff at the VAMC. Considering the diversity of professions at this VAMC, awareness was broadly conceptualized as familiarity with MI as well as its perceived impact on the health of service members and veterans. This confidential and anonymous survey was developed by clinicians and researchers at the data collection site. Responses were collected over a six-week period (August-September 2016).

The survey was uploaded to a third-party website specializing in online surveys, which assigned a unique internet link connecting directly to the survey. This link was included in an invitation e-mail sent out to all personnel through this VAMC’s listserv as well as posted on the local intranet. As a non-research activity, this survey was exempt from IRB approval and informed written consent. Survey responses are presented here descriptively – n (%). Questions and answer options are respectively detailed in the results.

Results

At the time of the survey, the center-wide listserv included n=900 personnel. This survey yielded n=106 (11.8%) responses.

Q1 – “In gauging your familiarity, please consider your understanding of what moral injury might mean. The more you know about moral injury, the higher you would rate it. The less you know, the lower you would rate it.”

Respondents chose one answer from five options. A total of n=9 (9%) reported being “extremely familiar”, n=28 (26%) “very familiar”, and n=18 (17%) “quite familiar” with MI. Taken together, these responses suggest n=55 (52%) had what could generally be described as a developed level of MI awareness.

Further, a total of n=32 (30%) reported being “somewhat familiar” with MI and n=19 (18%) “not at all familiar/never heard of it”. Taken together, these responses suggest n=51 (48%) had what could generally be described as an under-developed level of MI awareness.

[See Figure 1 in download]

Q2 – “Moral injury should be considered the domain of which service provider(s)? Check all that apply.”

Respondents chose from six answer options. Q2 was left blank by one respondent. A total of n=91 (87%) respondents identified MI as the domain of “psychologists, social workers, mental health counselors”, followed closely by n=86 (82%) who identified “chaplains”. Next, n=71 (68%) identified “physicians, physician assistants”, n=68 (65%) saw MI as the domain of “nurse practitioners, nurses, LPNs”, n=46 (44%) suggested “other service provider”, while n=13 (12%) answered “don’t know”.

[See Figure 2 in download]

Q3 – “Is moral injury relevant to the health of veterans?”

Answer options included: yes, no, maybe, and don’t know. Q3 was left blank by one respondent. To ensure meaningful interpretation, “no”, “maybe”, and “don’t know” responses were grouped into a single cell. A total of n=90 (86%) responded “yes” to MI being relevant to the health of veterans, only n=15 (14%) responded either “no”, “maybe”, or “don’t know”.

[See Figure 3 in download]

Q4 – “Is enough being done in the VA to address moral injury in veterans?”

Answer options included: yes, no, maybe, and don’t know. Q4 was left blank by two respondents. To

ensure meaningful interpretation, “no”, “maybe”, and “don’t know” responses were grouped into a single cell. Only n=4 (4%) responded “yes” to enough being done to address MI in VA settings, whereas n=100 (96%) responded either “no”, “maybe”, or “don’t know”.

[See Figure 4 in Download]

Discussion

In a survey distributed to personnel at a VAMC, self-perceived MI awareness was about evenly divided between developed and under-developed. Respondents saw MI as being chiefly the domain of mental hygiene service providers, followed by chaplains, medical, and nursing staff. Further, respondents overwhelmingly saw MI as relevant to the health of veterans, yet felt not enough is being done to address this issue in VA settings.

The findings suggest a mixed degree of MI awareness among respondents. It should, however, be noted that MI remains a relatively novel clinical construct and has only in recent years been identified as a focus of clinical concern. Interestingly, respondents identified MI as the domain of diverse service providers, including chaplains, reinforcing the view of MI as having a religious/spiritual dimension.4 This gives pause to consider what role interdisciplinary collaboration might play in effectively supporting veterans affected by MI.

These preliminary findings could serve to inform future research into MI. Possible research avenues might include a more detailed examination of MI awareness across service providers. Also, one qualitative line of inquiry might include examining the experiences of professionals who support veterans thought to be dealing with MI, the experiences of which might differ across disciplines. Recognizing any similarities and differences in these experiences could inform ongoing work into effectively supporting veterans found to be dealing with MI as well as serve to increase MI awareness in clinical settings.

There were several limitations associated with this survey which was, by design, descriptive and not part of a validated outcome measure. While all respondents were duly affiliated with the data collection site, presumably not all respondents were clinical service providers. The survey was also limited to a single VAMC. Further, the familiarity with MI reported by respondents was only self-perceived. As such, no causal or generalizable inferences can be made from the findings.

Notwithstanding these limitations, this survey provided preliminary insight into MI awareness among personnel at a clinical setting specialized in veteran health services and treatment. The findings highlight a critical need for continued efforts at increasing awareness of MI as well as developing support options which could be applied in health care settings. Increased awareness coupled with effective support options could ensure that VAMCs remain attentive to the needs of the veterans they serve as well as provide a consistent veteran experience practice standard.

 

Acknowledgements

The views expressed are those of the authors and do not reflect the official policy or position of the US Department of Veterans Affairs or Federal Government. Dr. Lockman is supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs, VISN 2 Center of Excellence for Suicide Prevention (Canandaigua, New York). The authors do not declare any conflicts of interest. Institutional support for this study was provided by the Canandaigua VA Medical Center and VISN 2 Center of Excellence for Suicide Prevention. This survey was conducted independent of any external funding mechanism.

References

1. Gray MJ, Schorr Y, Nash W, et al. Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther 2012; 43: 407-15. 2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009; 29: 695-706. 3. Houtsma C, Khazem LR, Green BA, et al. Isolating effects of moral injury and low post-deployment support within the U.S. military. Psychiat Res 2017; 247: 194-9. 4. Carey LB, Hodgson TJ, Krikheli L, et al. Moral injury, spiritual care and the role of chaplains: an exploratory scoping review of literature and resources. J Relig Health 2016; 55:1218-45.